Faculty Bibliography

First detected in Wuhan, China, the novel 2019 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped RNA beta-coronavirus responsible for an unprecedented, worldwide pandemic caused by COVID-19. Optimal management of immunosuppression in inflammatory bowel disease (IBD) patients with COVID-19 infection currently is based on expert opinion, given the novelty of the infection and the corresponding lack of high-level evidence in patients with immune-mediated conditions. There are limited data regarding IBD patients with COVID-19 and no data regarding early pregnancy in the era of COVID-19. This article describes a patient with acute severe ulcerative colitis (UC) during her first trimester of pregnancy who also has COVID-19. The case presentation is followed by a review of the literature to date on COVID-19 in regard to inflammatory bowel disease and pregnancy, respectively.

Background/UNASSIGNED:Clostridium difficile infection (CDI) is common in patients with inflammatory bowel disease (IBD), often leading to diagnostic confusion and delays in IBD therapy escalation. This study sought to assess outcomes after CDI in IBD patients exposed to new or escalated immunosuppressive therapy. Methods/UNASSIGNED:This multicenter retrospective cohort study included IBD patients with documented CDI at 4 academic medical centers. Data were abstracted from clinical databases at each institution. Outcomes at 30 and 90 days were compared between patients undergoing new or intensified immunosuppressive therapy and those without therapy escalation. Continuous variables were compared using t tests, and proportions using chi-square tests. Multivariable logistic regression was used to determine the association of individual variables with severe outcomes (including death, sepsis, and/or colectomy) within 90 days. Secondary outcomes included CDI recurrence, rehospitalization, worsening of IBD, and severe outcomes within 30 days. Results/UNASSIGNED:A total of 207 adult patients with IBD and CDI were included, of whom 62 underwent escalation to biologic or corticosteroid therapy (median time to escalation, 13 days). Severe outcomes within 90 days occurred in 21 (15.6%) nonescalated and 1 (1.8%) therapy-escalated patients. Serum albumin <2.5 mg/dL, lactate >2.2 mg/dL, intensive care unit admission, hypotension, and comorbid disease were associated with severe outcomes. Likelihood of severe outcomes was decreased in patients undergoing escalation of IBD therapy after CDI (adjusted odds ratio [aOR], 0.12) and increased among patients aged >65 years (aOR, 4.55). Conclusions/UNASSIGNED:Therapy escalation for IBD within 90 days of CDI was not associated with worse clinical outcomes. Initiation of immunosuppression for active IBD may therefore be appropriate in carefully selected patients after treatment of CDI.

Introduction: Clostridium difficile infection (CDI) occurs frequently in patients with inflammatory bowel disease (IBD) and is associated with increased disease activity. Due to concern for complications, immunosuppressive medication (ISM) is often withheld after CDI, although few data exist to inform this decision. This study aims to assess the influence of ISM on outcomes following CDI in IBD patients. Methods: This multicenter, retrospective cohort study was performed at 4 academic medical centers in New York City. Patient demographic and clinical data was abstracted from databases at each site for adult patients with an established diagnosis of IBD also diagnosed with CDI. Escalation of therapy was defined as initiation or dose escalation of corticosteroids or new biologic use following antibiotic therapy for CDI. Outcomes were assessed at 30 and 90 days after last positive C. difficile test. Continuous variables were compared using two-sided T-tests and proportions were compared using Chi-squared tests. Exact methods were used for expected cell size. Results: 207 patients met inclusion criteria (49 outpatient, 158 inpatient). Demographic information is listed in Table 1. Escalation of IBD regimen (Table 2) was more frequent in outpatients at 90 days (43% vs. 22%, P<0.01), with 49% (39/61) of ISM escalation occurring within 14 days of CDI.) Patients not escalated had higher rates of sepsis than escalated patients (11% vs. 2%, P=0.04). Severe outcomes (death, sepsis, or colectomy) at 90 days were markedly increased in the non-escalation group (15% vs 2%, P<0.01). There was no difference in CDI recurrence or rehospitalization between groups. Conclusion: In this multicenter study assessing outcomes of ISM use in patients with IBD and CDI, initiation of steroid or biologic therapy following CDI treatment was not associated with adverse clinical outcomes. While no difference was observed between CDI recurrence or rehospitalization among groups, sepsis and severe outcomes were significantly more common in patients not undergoing escalation. These data suggest that escalation of IBD therapy following CDI is not associated with worse clinical outcomes and a subset of patients may benefit from timely treatment of underlying inflammatory disease. Prospective studies are needed to validate these data and to inform clinical guidelines regarding the timing of ISM use following CDI

Background: There have been rare reports of niacin deficiency in patients with Crohn's disease. We report a case in which a patient presented with flushing. Clinical case: A 31-year old woman with a history of Crohn's disease was referred by her dermatologist for flushing. Six months prior, she began experiencing erythema of the chest area every other day. The flushing was described as uncomfortable and pruritic, and she found it distressing. There were no identifiable precipitating factors, such as foods, exercise, or stress. There had been no new medications prescribed. She denied use of dietary supplements or herbal remedies. The patient was evaluated by an allergist & immunologist and it was determined that the rash was not due to an allergic reaction. The patient's history was notable for necrotizing enterocolitis as a newborn, requiring a partial colectomy, and an ileostomy that was reversed 2 years later. At age 10 years she was diagnosed with rectal and perianal Crohn's disease. Due to lack of response to glucocorticoids, sulfasalazine, and infliximab, the patient underwent an ileostomy 4 months prior to the onset of flushing. Of note, the patient did not have evidence of ileal Crohn's disease. She also has a history of polycystic ovarian syndrome. Her medications at the time of presentation were an estradiol-norelgestromin 150-35 mcg transdermal patch twice weekly and sulfasalazine 2000mg daily. Laboratory evaluation revealed a low vitamin 25(OH)D level at 16 ng/ml. Normal blood test results were found for CBC, Sma20, TSH, FT4, lipid profile, as well as an evaluation for polycystic ovarian syndrome including PL, testosterone, DHEAS, 17OHP, ACTH, serum cortisol, and HbA1c. Normal laboratory values were found for flushing and nutritional parameters included vitamin A and B12, 24 hour urine 5HIAA/creatinine, plasma metanephrines, and histamine, serum calcitonin, chromogranin A, and tryptase. The pattern of the rash was reminiscent of a milder form of textbook pictures of pellagra, a condition commonly referred to as the 3 D's: dermatitis, diarrhea, and dementia. Niacin is primarily absorbed in the ileum, much of which had been surgically resected in this patient. Therefore nicotinic acid and nicotinamide levels were sent and found to be undetectable, <20 ng/ml. The patient was prescribed one flush-free niacin tablet (Nature Made, USP, 500mg inositol hexanicotinate), along with B complex and vitamin D3 2000IU daily. The flushing resolved within two weeks. A repeat serum nicotinamide level at that time had risen to 26 ng/nl. Seven months later, the patient remains symptom free. Conclusion: Niacin deficiency should be included in the differential diagnosis of flushing, particularly in patients with a history of surgically resected ileum, or active ileal disease, which can both interfere with niacin absorption